Improvement in Infection Prevention and Control Compliance at the Three Tertiary Hospitals of Sierra Leone following an Operational Research Study

Implementing infection prevention and control (IPC) programmes in line with the World Health Organization’s (WHO) eight core components has been challenging in Sierra Leone. In 2021, a baseline study found that IPC compliance in three tertiary hospitals was sub-optimal. We aimed to measure the change in IPC compliance and describe recommended actions at these hospitals in 2023. This was a ‘before and after’ observational study using two routine cross-sectional assessments of IPC compliance using the WHO IPC Assessment Framework tool. IPC compliance was graded as inadequate (0–200), basic (201–400), intermediate (401–600), and advanced (601–800). The overall compliance scores for each hospital showed an improvement from ‘Basic’ in 2021 to ‘Intermediate’ in 2023, with a percentage increase in scores of 16.9%, 18.7%, and 26.9% in these hospitals. There was improved compliance in all core components, with the majority in the ‘Intermediate’ level for each hospital IPC programme. Recommended actions including the training of healthcare workers and revision of IPC guidelines were undertaken, but a dedicated IPC budget and healthcare-associated infection surveillance remained as gaps in 2023. Operational research is valuable in monitoring and improving IPC programme implementation. To reach the ‘Advanced’ level, these hospitals should establish a dedicated IPC budget and develop long-term implementation plans.


Introduction
Infection Prevention and Control (IPC) is a cost-effective and key strategy to combat antimicrobial resistance (AMR), as it can be implemented in all sectors and settings, including those with limited resources [1]. For every infection prevented, there is one potential antibiotic treatment avoided, subsequently reducing the risk of AMR [2]. IPC is also crucial in preventing healthcare-associated infections (HAIs), another major global health challenge associated with increased mortality, morbidity, economic burden, and increased AMR [3,4].
Recognising the importance of IPC from the lessons learnt during the 2014-2016 Ebola outbreak, the Ministry of Health and Sanitation in Sierra Leone established a national IPC Programme [5]. The programme is led by the National IPC Unit (NIPCU) with a mandate to provide leadership and coordinate and monitor IPC implementation to strengthen IPC standards in all hospitals [2]. Each hospital established an IPC programme consisting of eight core components addressing different IPC aspects, in line with the WHO Guidelines on Core Components of IPC at the facility level [6]. However, data on IPC programme implementation in hospitals in Sierra Leone are scarce.
To analyse and improve IPC programme implementation at the hospital level, the WHO recommends use of the Infection Prevention and Control Assessment Framework (IPCAF) tool [7]. This is a standardised questionnaire with an associated scoring and grading system ranging from 'inadequate' to 'advanced' and an interpretation of the fourlevel grades (Table 1) used to assess the eight core components of an IPC programme [8]. This tool has been used by many countries to assess IPC programme implementation in hospitals. A WHO global survey on IPC implementation in hospitals from 81 countries showed a median score denoting an advanced level of implementation, but scores were significantly lower in low-income countries [9]. Similar studies conducted in Lira Hospital in Uganda, 11 tertiary hospitals in Bangladesh, and 12 tertiary hospitals in Pakistan documented weak implementation of the hospital IPC programmes as the majority of the hospitals scored 'basic' according to the IPCAF grading system [8,10,11]. The use of the IPCAF has enabled the identification of several bottlenecks in implementation, including limited financial resources and competing priorities. The findings of these studies, from comparable low-middle-income countries (LMICs), align with the few studies conducted in Sierra Leone [2,12].
The most recent study on assessing IPC programme implementation in Sierra Leone using the IPCAF tool was an operational research study conducted in 2021 by Kamara et al., a co-investigator on this paper (hereafter referred to as the baseline study) [13]. The baseline study found that the IPC programmes in three tertiary hospitals (Connaught, Ola During Children's and Princess Christian Maternity Hospitals) were sub-optimal as they scored 'Basic' according to the IPCAF grading. Several gaps were identified in the eight core components of the three hospitals' IPC programmes. These included the lack of a dedicated budget, lack of structured training for healthcare workers, lack of a professional development programme for IPC focal points, interrupted availability of IPC materials (aprons, gloves, and face masks), and lack of HAI surveillance. In light of this evidence, several recommendations ranging from low-cost to high-cost interventions were made to improve the implementation of IPC programmes in these hospitals [13].
In this study (hereafter referred to as the follow-up study), using an operational research approach, we aimed to describe the dissemination and implementation of these recommendations and measure any change in the IPC performance in the same three tertiary hospitals. Our specific objectives were to compare the baseline study, undertaken in August 2021, with this follow-up study, undertaken in March 2023, to (1) describe the dissemination activities, recommendations, and actions taken to improve the IPC programme implementation; (2) assess and compare the IPC performance scores, overall, and stratified by IPC core components; and (3) describe the current status of the gaps in the eight core components of IPC identified in the baseline study.

Study Design
This was a 'before and after' observational study using two routine cross-sectional assessments of IPC using the WHO-IPCAF tool.

General Setting
Sierra Leone is a coastal West African country sharing borders with Guinea and Liberia. The country is divided geopolitically into five regions and 16 districts with an estimated population of eight million [14]. The World Bank estimated the country's life expectancy at birth to be 60 years in 2020. More than half (57%) of the deaths are attributed to communicable diseases, with 16% of the Gross Domestic Product spent on health [15]. Healthcare services are largely provided by the public sector, and the public health sector is divided into primary, secondary, and tertiary care levels with about 27 government hospitals and over 1300 peripheral health units (PHUs). Primary, secondary, and tertiary care is provided at PHUs, district hospitals, and regional/national hospitals, respectively.

Study Sites
This was a follow-up study conducted at the same three tertiary hospitals (Connaught Hospital, Princess Christian Maternity Hospital-PCMH, and Ola During Children's Hospital-ODCH) as the baseline study [13].
Connaught Hospital, PCMH, and ODCH are public hospitals in Freetown, the capital of Sierra Leone. These are the only tertiary hospitals in Sierra Leone. Connaught Hospital has about 300 beds in 16 wards and 25 sub-units where both in-and outpatient services for medicine and surgery are provided [16]. PCMH has a bed capacity of 140 in eight wards and provides services for obstetrics and gynaecology, while ODCH has 139 beds in eight wards and provides services for paediatrics [17,18]. All three hospitals are teaching hospitals and part of the University of Sierra Leone Teaching Hospital Complex (USLTHC), established to support postgraduate clinical training.
All three hospitals have established IPC programmes with IPC committees and designated IPC focal points, whose key responsibilities are coordinating and implementing IPC activities at the hospital level.

Study Period
The baseline study was undertaken in August 2021, and the follow-up study was undertaken in March 2023.  [19]. These tools were used to disseminate the baseline research findings and recommendations to the identified decision-makers, influencers, and other relevant stakeholders. The dissemination details such as (1) mode of delivery (material used for dissemination), (2) to whom the findings and recommendations were disseminated, (3) where the dissemination was performed, and (4) when the dissemination was performed were extracted from the UN Special Programme for Research and Training in Tropical Disease (TDR) monitoring and evaluation (M&E) routinely collected data. We also collected usage statistics from social media platforms as well as citations from the published paper.
The list of recommendations made was prepared by reviewing the baseline study manuscript and dissemination materials. A record of actions taken was obtained from the original principal investigator, and the TDR M&E routinely collected data to supplement this information. The IPCAF Tool has a total score of 100 points assigned for each CC, and thus the highest possible overall IPCAF score (IPC compliance score) for all eight components is 800. The tool has a grading system for the overall compliance score denoting a range from inadequate to advanced IPC compliance (Table 1). For this follow-up study, we applied the same approach at the core component level to grade the individual core components based on the obtained score using the following scale: (i) inadequate (0-25); (ii) basic (25.1-50); (iii) intermediate (50.1-75); and (iv) advanced (75.1-100). In presenting these categories, we developed a colour coding scheme from red denoting inadequate through green denoting advanced.
This follow-up study used routinely collected data by the IPC focal points within each hospital using the WHO IPCAF tool in consultation with relevant key stakeholders. The completed information was cross-validated by the principal investigator through a review of documents and direct observation where necessary.
The data collected were entered into a Microsoft Excel spreadsheet by the lead researcher. To ensure data accuracy, the principal investigator undertook a review of the datasets to detect any missing or incomplete data. Where possible, scores were validated by reviewing supporting documentation (for example, the training logs). The overall and core-component scores were calculated for each hospital. A descriptive analysis of each core component of the IPC programmes in all three hospitals was performed, followed by a comparative analysis with the findings from the baseline operational research. In our results, we reported the actual scores and calculated the absolute percentage change in IPC compliance.

Dissemination Activities and Recommendations
The research team of the baseline study [13] used several dissemination methods and materials to ensure adequate uptake of research findings and recommendations. These included a publication, an elevator pitch, a plain English summary, and a Microsoft Pow-erPoint 2013 presentation, the latter being the most common method used. The baseline research findings and recommendations were presented to a wide range of audiences that included researchers, academicians, policymakers, and healthcare workers at different times and places (Table 2). Out of the eight recommendations divided into low, medium, and high-cost from the baseline study, two had been fully implemented and four had been partially implemented (Table 3) [13]. Table 3. List of recommendations from the baseline study conducted in 2021 for improving IPC performance in three tertiary health facilities in Sierra Leone and status of actions as of April 2023 [13]. Partially Implemented

Cost of Implementation * Recommendation Action Status Details of Action
Technical and financial support provided to the national IPC unit and technical support to hospital IPC programmes. However, there is no dedicated budget at the facility level.
* Source [13]. Fully implemented-all actions taken and no further intervention required; partially implementedactions taken but needs further intervention; not implemented-no action taken, IPC-Infection Prevention and Control; IPCAF-Infection Prevention and Control Assessment Framework; low cost-activities undertaken within the existing resources, infrastructure, and training programmes; medium cost-activities requiring a moderate increase in existing resources, infrastructure, and training programmes; high cost-the creation of a dedicated budget, increased funding, and improvement to existing workforce and infrastructure.

Overall and Individual Core Component Compliance
The overall IPC compliance scores for Connaught Hospital, ODCH, and PCMH in 2023 were 482.5, 458.5, and 511, respectively, with PCMH, which had the lowest score in 2021, having the highest score in 2023. All three hospitals fell within the range of the 'Intermediate' level (400-600) according to the WHO IPCAF grading. There was an improvement in IPC compliance from 2021 to 2023 in all three hospitals as shown by the increased absolute percentage scores, with PCMH showing the highest improvement of 26.9% (Table 4).
There were increased compliance scores across all eight core components in the three hospitals' IPC programmes from 2021 to 2023, with the majority of the scores ranging from 'Basic' to 'Intermediate'. A two-level improvement was seen in the 'IPC guidelines' (CC2) and 'multimodal strategies' (CC5) compliance from 'Basic' to 'Advanced' for the three hospitals, making them the core components with the highest level of compliance. Improved compliance from 'Inadequate' to 'Basic' was also seen in the 'Monitoring/audit of IPC practice' (CC6) for the three hospitals' IPC programmes. Only PCMH recorded an improvement in 'HAI surveillance' (CC4) and 'IPC education and training' (CC3) compliance (Table 5).   There were increased compliance scores across all eight core components in the three hospitals' IPC programmes from 2021 to 2023, with the majority of the scores ranging from 'Basic' to 'Intermediate'. A two-level improvement was seen in the 'IPC guidelines' (CC2) and 'multimodal strategies' (CC5) compliance from 'Basic' to 'Advanced' for the three hospitals, making them the core components with the highest level of compliance. Improved compliance from 'Inadequate' to 'Basic' was also seen in the 'Monitoring/audit of IPC practice' (CC6) for the three hospitals' IPC programmes. Only PCMH recorded an improvement in 'HAI surveillance' (CC4) and 'IPC education and training' (CC3) compliance (Table 5). There were increased compliance scores across all eight core components in the three hospitals' IPC programmes from 2021 to 2023, with the majority of the scores ranging from 'Basic' to 'Intermediate'. A two-level improvement was seen in the 'IPC guidelines' (CC2) and 'multimodal strategies' (CC5) compliance from 'Basic' to 'Advanced' for the three hospitals, making them the core components with the highest level of compliance. Improved compliance from 'Inadequate' to 'Basic' was also seen in the 'Monitoring/audit of IPC practice' (CC6) for the three hospitals' IPC programmes. Only PCMH recorded an improvement in 'HAI surveillance' (CC4) and 'IPC education and training' (CC3) compliance (Table 5). There were increased compliance scores across all eight core components in the three hospitals' IPC programmes from 2021 to 2023, with the majority of the scores ranging from 'Basic' to 'Intermediate'. A two-level improvement was seen in the 'IPC guidelines' (CC2) and 'multimodal strategies' (CC5) compliance from 'Basic' to 'Advanced' for the three hospitals, making them the core components with the highest level of compliance. Improved compliance from 'Inadequate' to 'Basic' was also seen in the 'Monitoring/audit of IPC practice' (CC6) for the three hospitals' IPC programmes. Only PCMH recorded an improvement in 'HAI surveillance' (CC4) and 'IPC education and training' (CC3) compliance (Table 5).

Baseline Gaps Status in 2023
In the baseline study, 22 gaps were documented in the different components of the IPC programmes in the three hospitals. Of these, five had been addressed whilst the others still existed in 2023. Improvements were seen in 'IPC guidelines' (CC2) and 'multimodal strategies'(CC5) as more than half of the gaps no longer existed. The core components with little or no improvement were the 'IPC programs' (CC1), 'workload, staffing and bed occupancy' (CC7), and 'built environment, materials, and equipment' (CC8) ( Table 6).

Discussion
This is the first follow-up study assessing the change in IPC programme implementation at the tertiary hospitals of Sierra Leone following a baseline operational research. We showed that several communication materials were used to disseminate the baseline study findings [13], which enabled the uptake of recommended actions. Additionally, there was an improvement in the overall IPC compliance score for each hospital as they all moved from 'Basic' to 'Intermediate' levels according to the IPCAF grading system.
Our study affirms the value of using the standardised IPCAF tool at regular intervals to assess IPC performance and inform change. However, using the tool to generate findings alone is not enough to foster change without dissemination of the recommendations. We recommend implementing a comprehensive communication of the findings using the tools we described here, evidence briefs, and presentations to enhance the awareness and take-up of the recommendations. Other factors that enabled this positive change included the political will of the senior leadership in the Ministry of Health and Sanitation and their involvement throughout the research cycle. Additionally, involvement of the principal investigators in both operational research studies improved our ability to describe the actions taken between the studies and make an association with the subsequent improvement in scores in some core components. We accept that direct attribution is not possible.
In these three hospitals, we observed that all the low-cost recommendations were implemented. The likely reason is that they can be undertaken within existing resources, infrastructure, and training programmes. Recommendations that were considered highcost remained as gaps. Key among these was the need for a dedicated budget for IPC implementation at every hospital. Additionally, action is required at the national level to improve workload; staffing and bed occupancy (CC7); and environments, materials, and equipment for IPC (CC8) at these three hospitals.
Our second objective was to measure the change in compliance between the two study periods. There was a noticeable improvement in all three hospitals' IPC programmes, with at least a 15% absolute increase in IPC performance. This implies that many of the core components of these hospital IPC programmes were implemented appropriately. We believe that the baseline study recommendations and their effective dissemination contributed to the actions taken by the different hospitals' IPC teams, leading to an improvement in the follow-up study.
For the different core components, there was a two-level (from 'Basic' to 'Advanced') improvement in guidelines and multimodal strategy, while the least improvement was seen with HAI surveillance. The marked improvement seen in the IPC guideline was mainly due to updating and disseminating the national IPC guideline, which was being revised during the baseline study. The improvement seen in multimodal strategies can be associated with the mentorship and trainings on the multimodal strategy conducted by the lead PI of the baseline study as he noticed that it was challenging for IPC focal points to apply the concept of the multimodal strategy. The PIs of the baseline and follow-up operational research studies will continue to provide technical and operational support to the national IPC unit and hospital IPC teams to ensure the full implementation of operational research recommendations.
The recently published WHO global report on IPC implementation at the hospital level documented an improvement in IPC programmes across all six WHO regions (8). This report further highlighted those hospitals in low-income settings, such as Sierra Leone, that are yet to achieve the WHO-recommended 'Advanced' level. This is in keeping with our follow-up study findings as none of the three hospitals scored 'Advanced level'.
There are still some critical gaps that must be addressed in all three hospital IPC programmes to reach the 'Advanced' level. These gaps include the lack of a dedicated budget, lack of regular IPC training for healthcare workers, and lack of routine HAI surveillance. Our findings are similar to a study conducted in Bangladesh where only 30% of the hospitals included in the survey conducted regular IPC training for staff, and none of the 11 hospitals had an HAI surveillance system in place [11]. We believe that the gaps that are still present needed more time and financial resources for them to be addressed. A longer period of follow-up might be advantageous to fully see the positive impact of operational research.

Recommendations for Policy and Practice
For these hospitals to attain the 'Advanced' level according to the IPCAF grading system, we therefore recommend the following: First, there should be continued dissemination of both the baseline and follow-up operational research findings to improve awareness. Additionally, to ensure appropriate uptake of the recommendations, there should be constant engagement with the hospital management and other IPC stakeholders. Second, there should be a dedicated budget in each of these hospitals for improvement in the implementation of IPC core components. Third, the hospital management should prioritise HAI surveillance activities and better access to international funding to improve microbiology capacities: funding is partially supported in a current Fleming Fund grant. Finally, some actions can only be taken at the national level including the improvement of workload; staffing and bed occupancy (CC7); and environments, materials, and equipment for IPC (CC8).
Our study has several strengths. First, data collection was carried out by IPC focal persons and validated by the principal investigator, who has good knowledge of IPC. Second, we used a structured and validated data collection proforma, the WHO IPCAF tool, which facilitated an appropriate comparison with the baseline study in which the same tool was used. Third, the recommendations from the baseline study were clearly stated as low cost through to high cost, supporting the investigators in assessing the status of recommendations and effective actions taken. Fourth, we adhered to 'STROBE' (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for data collection and the reporting of study findings [20].
There are limitations to our study. While this survey covers all three tertiary hospitals in Sierra Leone, we recognise that this is a small sample size compared to other national surveys. A qualitative approach would have added more value to our findings in identifying the root causes of poor performance in IPC implementation. The IPCAF tool is a self-assessment tool and might introduce some biases as responses given by facilities cannot be easily verified. Whilst we can mitigate such limitations by a cross-validation process, we cannot eliminate them.

Conclusions
There was an improvement in the implementation of the IPC's eight core components at Connaught Hospital, PCMH, and ODCH as they moved from the 'Basic' to 'Intermediate' level according to the IPCAF grading from the years of 2021 to 2023. This improvement can be attributed to several factors including the recommendations made from the baseline operational research study, the actions taken, the dissemination of research findings, and the continued technical support to the national IPC unit and hospital IPC programme by both operational researchers. Finally, we have demonstrated the importance of operational research to monitor and improve programme implementation at the hospital level, which can also inform recommendations for actions at the national level. Funding: The Government of the United Kingdom of Great Britain and Northern Ireland, represented by its Department of Health and Social Care (DHSC), has contributed designated funding for this SORT IT-AMR initiative, which is branded as the NIHR-TDR partnership, grant number AMR HQTDR 2220608. The APC was funded by DHSC. TDR can conduct its work thanks to the commitment and support from a variety of funders. A full list of TDR donors is available at https://tdr.who.int/about-us/our-donors (accessed on 4 February 2021).
Intitutional Review Board Statement: Ethics approval was obtained from the Sierra Leone Ethics and Scientific Review Committee (SLESRC, 9 March 2023) and the Ethics advisory group of the International Union Against Tuberculosis and Lung Disease, Paris, France (EAG, 28 March 2023). Permission to use the data was obtained from the national IPC unit and the hospital managements, in Freetown, Sierra Leone.

Informed Consent Statement:
As we used secondary anonymized data, the issue of informed consent did not apply.